Last week was the sad one-year anniversary of the death of Junior Seau. Junior was one of the uniquely good people in public life and professional sports. He was a star in the NFL for an incredible 20 years and was a pro bowl linebacker for 12 of those seasons. I was privileged to see Junior often as a season ticket holder at “The Murph”, San Diego’s Jack Murphy Stadium, where the Chargers play their home games and see his smile light up the entire room at his restaurant in Mission Valley. He devoted his enormous energies during his playing career and afterwards for his short retirement to helping kids succeed and prosper in spite of tough financial and home environments and combating drug addiction. Unfortunately, Junior did not devote the same energy to his own psychological health and suffered in silence with a number of personal demons. Junior was 43 and less than two years out of his playing career when he committed suicide by shooting himself in the chest (as did NFL defensive back Dave Duerson the year before) donating his brain to science. Examination of Junior’s brain showed he suffered from CTE, chronic traumatic encephalopathy, incurred from repeated concussions, the same diagnosis given Dave Duerson.

Throughout his stellar two decade NFL career, Junior was held up by the press and his adoring fans as a superhero that was totally invincible. He was impervious to the incredible traumas of NFL football, including multiple concussions, and viewed any injury as a mere inconvenience that he routinely played through. He didn’t miss as much as a training session let alone a game for injuries that would have sidelined other NFL players for weeks. “It’s all about the respect that you can only earn on the field…it’s about courage,” he said to San Diego Charger trainer James Collins during many painful treatments. So as the months following his retirement unfolded and the demons in Junior’s head started shouting louder the toughness that made him famous, also made it impossible for him to even consider asking for help. As Peter King wrote in his Sports Illustrated eulogy, “Superman never asks for help”.

Junior shared a lot of the personal attributes of surgeons; an incredible inner drive, self-demand for perfection, unlimited energy and willingness to take on incredible personal challenges. Actually these are many of the attributes of people who are attracted to becoming pilots. The FAA (but not organized medicine) has developed some metrics for self-regulation and internal guidance. I’ve commented before in this blog that planning and carrying out an operation takes a lot of the same thought process and organization as flight planning – plan the flight and fly the plan. There are hundreds of flight planning methods to evaluate and weigh mission risks including both paper and web based risk assessment tools. There are exactly zero such tools for surgeons. The FAA calls these FRATs, Flight Risk Assessment Tools that use a computer algorithm to assign a numeric risk to the mission taking into account four basic components. These four factors are (1) you – the pilot (2) the aircraft (3) the environment (4) mission – type of flight. Plugging some estimates of risks in each category the website prints out a colorized grid and percent risk for each phase of flight. This allows the pilot to mitigate risks and tailor the flight plan to assure the safest outcome.

Surgeons make these types of decisions daily. We call it balancing risks vs. benefits and we routinely discuss this in detail with our patients and their families when we advise the patient to consent to surgery. Our informal operative planning takes into account only three of the four factors that are assessed with FRATs: (1) the patient (2) disease process and chance for cure (3) chances of complications. But exactly where in this equation do we take into account our own current state of fitness to operate on the patient?

Certainly the negative impact of fatigue is one of the most critical factors on safety and I have blogged about that in detail in previous posts. Again we can look to the FAA that has promoted a self-awareness program for high reliability performance in pilots known by the acronym “I’M SAFE” which is called the flight fitness checklist. This challenges the user (pilot) to assess his or her own personal fitness that might negatively impact their capability to fly the airplane at that time in that flight environment and that route. The letters stand for:

I – Illness: Do I have an illness or any symptoms of illness?

M – Medication: Have I been taking prescription or over-the-counter drugs?

S – Stress: Am I under psychological pressure from the job? Worried about financial matters, health problems or family discord?

A – Alcohol: Have I been drinking within eight hours? Within 24 hours?

F – Fatigue: Am I tired and not adequately rested?

E – Eating: Am I adequately nourished?

These are the questions that we surgeons should ask ourselves and make as objective assessment as we can regarding our own personal fitness to do a complex and demanding operation. Are you tired or stressed out? Is this a case you rarely do? Did you take some cold medication and have a fuzzy head? Were you called in unexpectedly from a party and had a few cocktails? If we were truly self-assessing our ability to do the surgery would you ask a partner to do it – or to scrub in for the critical parts to help? Can you do it in the morning instead of tonight? And if there is nobody else and no way to put it off do you tell the OR team that you’re tired or stressed and to keep an extra close lookout for anything that might negatively impact the case and the patient’s safety? As advocates and adopters of The High Reliability Mindset, we must never be afraid or too proud to ask for help. If you don’t you should, and even though we are supermen and superwomen, sometimes even superman needs to ask for help. Junior would be still alive today, smiling his beaming smile, enjoying his children and helping hundreds of others with his good deeds if he had only been able to tell someone he needed help.

One Response

This blog is near & dear to my heart & to what I try to impart to my residents & medical students every day: If you don’t take care of yourself, you will never be able to provide high quality care & safety to your patients, nor for anyone else whom you care about. Unfortunately, physicians & others (psychologists, clergy, athletic stars–such as Junior) often feel we are held up to a higher standard in this regard: we tend to believe it is “weak” to ask for help, or that we may be viewed as incompetent if we do so. I mean, we should be able to fix ourselves being doctors, for God’s sake—right?! These distorted beliefs are rooted in fear and, as I also tell my learners, any decisions made from fear (except walking across the street without looking & the like), are always wrong. Fear, or more accurately, “anxiety” (as “fear” is a normal, adaptive mechanism which keeps us safe) is a highly-charged emotional response whose basis is always irrational & stems from old conflicts/core beliefs. For example, the doctor for whom nothing is ever good enough so he constantly pushes himself beyond the brink in terms of exhaustion. His self-flagellating behaviors derive from his core belief of being unworthy; a core belief which he developed as a young child as the direct result of his father repeatedly telling him he would “never be good enough to amount to anything.” So, even as an adult who is wildly successful by any measure, no matter how much he achieves or accomplishes, he will never feel it is enough (that HE is enough). In helping surgeons & others like Junior to practice more self-care, we need to also teach them about introspecting into possible underlying fears/anxiety.
At our academic health center, we are working right at this very moment to create an environment…a “culture”…for the new interns across all specialties (including surgery & the surgical subspecialties) where they will meet regularly and be invited to talk about wellness and their own internal obstacles to self-care. Until we create a culture for those in professions where others may put them on a “pedestal,” we will continue to see tragedies occur, such as the great loss of someone as wonderful and amazing as Junior Seau.
I really love the IM SAFE acronym and will use it now in my own practice, as well as in my teaching—thank you!